1. Head Injury in Sport James R. Borchers, MD The Ohio State University Assistant Clinical Professor Team Physician Dept of Family Medicine Division of Sports Medicine

2. Objectives Define and discuss various types of head injuries in sport Define and discuss various types of head injuries in sport Review initial evaluation of an athlete with a head injury Review initial evaluation of an athlete with a head injury Review concussion evaluation and treatment Review concussion evaluation and treatment Discuss return to play guidelines for an athlete with a head injury Discuss return to play guidelines for an athlete with a head injury

3. Head Injuries in Sport Actual number of injuries unknown because many are not reported by the athlete Actual number of injuries unknown because many are not reported by the athlete Most head injuries in sport are minor: Most head injuries in sport are minor: –Sports are third behind MVA and falls as cause of minor head injuries –Most common head injury in sports is a concussion

4. Head Injuries in Sport NCAA Injury Surveillance System developed in 1982 and has guided the NCAA regarding head injury in sport: NCAA Injury Surveillance System developed in 1982 and has guided the NCAA regarding head injury in sport: –1984-1991 the highest # of head injuries were in ice hockey, followed by football,field hockey, women’s lacrosse and men’s soccer. –Football had the highest concussion rate

5. Head Injuries in Sport 1995-1996 data showed an increase in the number of head injuries 1995-1996 data showed an increase in the number of head injuries –More aggressive play and increased contact –Better reporting and diagnosis of head injuries

6. Types of Head Injuries Focal Focal –Blunt trauma –Usually associated with LOC and focal neuro deficits –Subdural hematoma, epidural hematoma,cerebr al contusions and intra cerebral hemorrhage Diffuse Diffuse –Not associated with focal intracranial injuries –Severity depends on the amount of anatomic disruption that occurs –Concussion is the most common type

7. Subdural Hematoma Often LOC, focal deficits and slow deterioration in mental status Often LOC, focal deficits and slow deterioration in mental status Low pressure disruption of venous blood supply Low pressure disruption of venous blood supply Two types: simple and complex Two types: simple and complex –Depends on the presence of underlying cerebral contusion or edema

8. Subdural Hematoma

9. Epidural Hematoma LOC at time of injury, lucid interval and then CNS deterioration LOC at time of injury, lucid interval and then CNS deterioration Associated with disruption of the middle or other meningeal arteries Associated with disruption of the middle or other meningeal arteries Must have a high suspicion for injury based on mechanism and exam Must have a high suspicion for injury based on mechanism and exam Neurosurgical emergency Neurosurgical emergency

10. Epidural Hematoma

11. Concussion

12. Concussion Most common head injury in sports Most common head injury in sports Term has been used since the 10 th century AD, first described as an abnormal physiologic state without gross traumatic lesions of the brain Term has been used since the 10 th century AD, first described as an abnormal physiologic state without gross traumatic lesions of the brain Pathophysiology of concussion is still not well understood Pathophysiology of concussion is still not well understood

13. Concussion In 2004, the Concussion in Sport Group (CSIG) Prague statement defined concussion: –Concussion is defined as a complex physiological process affecting the brain, induced by traumatic biomechanical forces. –Caused by a direct blow to the head, face, neck, or elsewhere on the body with an impulsive force transmitted to the head

14. Concussion –Typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously –May result in neuropathological changes reflecting a functional disturbance rather than a structural injury –Graded set of clinical syndromes that may or may not involve LOC –Associated with grossly normal neuroimaging studies

15. Concussion Symptoms Early Early –Headache –Dizziness –Confusion –Tinnitus –Nausea –Vomiting –Loss of balance Late Late –Memory Disturbances –Poor Concentration –Irritability –Sleep disturbances –Fatigue –Personality changes

16. Concussion Types Simple Simple –Symptoms resolve over 7 – 10 days –Limit physical activity –No neuropsychiatric testing required –Rest until all symptoms resolve and then graded program of exertion before return to sport

17. Concussion Type Complex Complex –Persistent symptoms even with exertion, specific sequelae, LOC> 1 min, prolonged cognitive deficit –Neuropsychiatric testing indicated –Multidisciplinary approach

18. Concussion Evaluation Begins with basic life support: Begins with basic life support: –Airway, Breathing and Circulation Determine if there is any loss of consciousness: Determine if there is any loss of consciousness: –If LOC exists the athlete must be suspected to have a cervical spine injury and treated appropriately

19. Concussion Evaluation If the athlete can be moved to the sideline a neurologic exam should be performed If the athlete can be moved to the sideline a neurologic exam should be performed Evaluate long and short term memory Evaluate long and short term memory –Assess memory using sport specific questions; orientation questions have poor yield for assessing memory Assess for retrograde and antegrade amnesia Assess for retrograde and antegrade amnesia Monitor frequently Monitor frequently

20. Concussion Evaluation Preparticipation Exam Preparticipation Exam –Baseline evaluation for cognitive screen and symptom score –Sport Concussion Evaluation Tool (SCAT) –ImPact

21. Concussion Grading No consensus exists regarding the grading of concussions No consensus exists regarding the grading of concussions There is very little evidence to support any specific grading scheme There is very little evidence to support any specific grading scheme Most have been based on expert opinion and limited data Most have been based on expert opinion and limited data Glasgow Coma Scale is the only validated scale for use in head injury Glasgow Coma Scale is the only validated scale for use in head injury

22. Concussion Grading Scales

23. Concussion Grading In 2004, the CISG recommended that no specific system be used to grade concussions but that a clinical construct evaluating individual signs and symptoms be used to determine concussion severity and guide management and return to play In 2004, the CISG recommended that no specific system be used to grade concussions but that a clinical construct evaluating individual signs and symptoms be used to determine concussion severity and guide management and return to play

24. Concussion Evaluation Neuropsychological testing has been shown to be of value when evaluating concussion Neuropsychological testing has been shown to be of value when evaluating concussion –Baseline testing is needed for accurate results and periodic baseline updates are recommended –Players may return to baseline testing while still symptomatic –Aid to clinical decision making

25. Concussion Evaluation Neuroimaging is not usually necessary and is usually normal with a concussion injury Neuroimaging is not usually necessary and is usually normal with a concussion injury –CT scan initial study of choice if concurrent focal injury is present –MRI better for anatomy and if imaging is needed 48 hours or more post injury Newer modalities (PET scan, structural MR modalities) promising but not established for use in concussion Newer modalities (PET scan, structural MR modalities) promising but not established for use in concussion

26. Concussion Management Dependent on individual guidelines Dependent on individual guidelines Consensus that any athlete that has signs or symptoms of concussion should be removed from the event immediately and should not return if signs or symptoms persist at rest or with exercise Consensus that any athlete that has signs or symptoms of concussion should be removed from the event immediately and should not return if signs or symptoms persist at rest or with exercise

27. Concussion Management CSIG 2004 states when any player shows any signs or symptoms of concussion CSIG 2004 states when any player shows any signs or symptoms of concussion –No RTP in game or practice –Regular monitoring –Player medically evaluated –RTP must follow medically supervised stepwise process

28. Concussion Management

30. Should follow a stepwise approach Should follow a stepwise approach At each level the athlete should be asymptomatic before progressing to the next stage At each level the athlete should be asymptomatic before progressing to the next stage 24 hours between stages 24 hours between stages If an athlete is symptomatic at any stage, the athlete should drop back to the previous level and try to progress again in 24 hours If an athlete is symptomatic at any stage, the athlete should drop back to the previous level and try to progress again in 24 hours

31. Concussion Management Step wise progression Step wise progression –No activity, complete rest –Light aerobic exercise –Sport specific exercise –Non-contact drills –Full contact training –Game play Should be followed for any concussion occurrence Should be followed for any concussion occurrence

32. Concussion Guidelines NATA NATA Allows RTP same day Allows RTP same day –Symptoms < 20 min –No symptoms with exertion –No LOC –No amnesia Team Physician Consensus Statement Team Physician Consensus Statement –No evidence based data for RTP same day

33. Post Concussion Risks

34. Second Impact Syndrome Most serious risk of premature return to play following a concussion Most serious risk of premature return to play following a concussion Any insult to the head following premature return to play causes instantaneous collapse and death Any insult to the head following premature return to play causes instantaneous collapse and death Thought to be due to loss of autoregulation of the brain’s blood supply Thought to be due to loss of autoregulation of the brain’s blood supply Researchers have questioned its existence Researchers have questioned its existence

35. Postconcussive Syndrome Constellation of symptoms that persist following minor head injury Constellation of symptoms that persist following minor head injury Criteria defined in DSM-IV are viewed as too strict and often clinical judgment is needed to evaluate on an individual basis Criteria defined in DSM-IV are viewed as too strict and often clinical judgment is needed to evaluate on an individual basis Multidisciplinary approach to treatment Multidisciplinary approach to treatment Beta-blockers, SSRIs and TCAs can be used Beta-blockers, SSRIs and TCAs can be used

36. Chronic Traumatic Encephalopathy Premature loss of normal CNS function due to multiple blows to the head Premature loss of normal CNS function due to multiple blows to the head May occur in athletes with no LOC and it is difficult to predict which athletes are at risk for developing this syndrome May occur in athletes with no LOC and it is difficult to predict which athletes are at risk for developing this syndrome “Punch drunk syndrome” “Punch drunk syndrome” Syndrome occurs in 9-25% of professional boxers, depends on # of fights and length of their career Syndrome occurs in 9-25% of professional boxers, depends on # of fights and length of their career

37. Pediatric Concussion Physical and cognitive rest Physical and cognitive rest Neuropsychiatric testing difficult Neuropsychiatric testing difficult Stepwise progression suggested Stepwise progression suggested Stay conservative Stay conservative

38. Prevention Multiple factors can help with head injury prevention in sport: Multiple factors can help with head injury prevention in sport: –Equipment modification –Rule enforcement and changes as necessary –Education of proper sport specific techniques No clinical evidence that concussion in sport can be prevented No clinical evidence that concussion in sport can be prevented

39. Conclusion Most head injuries in sport are mild but there is no such thing as a minor head injury Most head injuries in sport are mild but there is no such thing as a minor head injury Appropriate evaluation will help to avoid complications of an athletic head injury Appropriate evaluation will help to avoid complications of an athletic head injury When in doubt, sit them out When in doubt, sit them out Clinical judgment and experience are important when dealing with head injuries in sport Clinical judgment and experience are important when dealing with head injuries in sport

40. Thank You